Browsing by Author "Bhattarai, A"
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Publication A Retrospective study of Intussusception of the bowel in adults(Institute of Medicine, 2015) Bhattarai, A; Poudyal, S; Bhandari, RS; Lakhey, PJ; Singh, KPAbstract Introduction: Intussusception is the leading cause of intestinal obstruction in children. In contrast to childhood intussusception, adult intussusception accounts for only 5% of all intussusceptions with 90% having a lead point, a well-defined pathological abnormality. Adult intussusceptions pose a further challenge as they are often presented with acute, subacute or chronic non-specific symptoms. Computed tomography is the most sensitive diagnostic modality and can distinguish between intussusception with and without a lead point. Surgery is the definitive treatment of adult intussusceptions. So the aim was to evaluate adults with intussusception in and to assess its etiology, clinical features, diagnosis and management. Methods: A retrospective review of adults aged >16 years with a diagnosis of intussusceptions between 1998- 2013 was done. Results: There were 22 cases of adult intussusceptions. Mean age was 44 years (17-86 years). Abdominal pain, nausea, vomiting and rectal bleeding were the most common symptoms. There were 2 cases of retrograde jejunogastric intussusception, 5 cases of jejunojejunal intussusceptions, 3 cases of ileoileal intussusceptions, 11 cases of ileocolic intussuscetpions and 1 case of colocolic intussusception. In seventeen cases, the lead point for intussusception was identified out of which 13 cases had benign pathology and 4 cases had malignant pathology. In five cases cause was not found. All cases were treated surgically except one case of jejunogastric intussusception which was reduced endoscopically. Mean duration of hospital stay was 13 days (5-30 days). Postoperative period was uneventful except surgical site infection in 8 cases and 1 case developed ECF which was managed conservatively. There was one mortality because of chest infection. Conclusion: Adult intussusception is an unusual and challenging condition having a well- defined pathological abnormality in most of the cases. Treatment usually requires resection of the involved bowel segment. Keywords: Adult Intussusception, Computed tomography, SurgeryPublication A Study of Trauma Patients in the Emergency Department of a Tertiary Care Hospital in Nepal during Lockdown in COVID-19 Pandemic(Kathmandu University, 2022) Shrestha, SK; Dahal, S; Bhattarai, AABSTRACT Background The nationwide lockdown was imposed upon by the Government of Nepal with regards to the COVID-19 pandemic. Even during times of limited mobility and travel, trauma cases were presenting to the hospital. Objective To asses trauma patterns among patients presented to the Emergency department in Dhulikhel hospital during the lockdown period. The assessment of the burden of trauma during the pandemic could aid in planning allocation of resources and improving trauma care. Method A retrospective cross-sectional study design was used to assess all patients with a history of trauma during the period of lockdown announced by the Government of Nepal for COVID-19 from March 24 to June 14, 2020. Result Among 2097 patients that visited the emergency department, 23% were trauma cases. In comparison to the corresponding time-period in 2019, trauma cases reduced by more than half (54.5%). The majority of patients utilized ambulances as a means of transportation; a few patients utilized Dhulikhel emergency medical services. The most common mechanism of injury was fall injury, followed by motor vehicle accident and physical assault. Traumatic brain injury occurred in 30% of patients. Of all patients, 71% were discharged after initial treatment, 26% were admitted to different wards and 3% were referred to other health centres. Conclusion Fall injury is a crucial public health concern followed by motor vehicle accident among trauma patients even during the pandemic condition. Thus, emergency rooms should aid in planning for preparedness, mitigation of trauma during situations like these, in planning the allocation of resources and improving trauma care. KEY WORDS COVID-19 pandemic, Lockdown, TraumaPublication Atrial septal defect closure with axillary mini thoracotomy and total peripheral cannulation: a novel approach(Institute of Medicine, 2017) Bhattarai, A; Pradhan, BAbstract Ostium secundum atrial septal defect (ASD II) is one of the most common congenital heart defects (CHDs), occurring in 5% to 10% of children (1) and in 30% of adult patients with CHD (2,3). Surgical closure has been considered for many years the gold standard treatment for patients with an ASD II. Operative mortality is low (0% to 3%) (4–6) and long-term survival is high (25-year survival of 92%) (7). Here, we describe our initial experience with minimally invasive approach using total peripheral cannulation (TPC) and an axillary minithoracotomy (AMT) 4-5 cm long incision for surgical closure of an ASD. In our knowledge ASD closure with axillary mini-thoiracotomy is for the first time in the country.Publication Clinical Profile and Diagnosis of Obstructive Sleep Apnea Syndrome using Overnight Polysomnography in a Tertiary Care Hospital(Kathmandu University, 2021) Pokharel, M; Shrestha, BL; Dhakal, A; Rajbhandari, P; Shrestha, KS; KC, AK; Bhattarai, A; Karki, DRABSTRACT Background Obstructive sleep apnea is a highly prevalent yet largely under-diagnosed disease that poses a significant burden on the healthcare system. Objective To determine the role of predictors for Obstructive sleep apnea syndrome and its severity in Nepalese population. Method Prospective and analytical study conducted in the Department of Otorhinolaryngology and Head and Neck surgery at Kathmandu University Hospital between March 2018 and June 2020. A total of 85 adult patients with Obstructive sleep apnea with an Epworth sleepiness score greater than 10 were included. Overnight polysomnography was done and scoring of sleep associated events were done according to the American Academy of Sleep Medicine criteria. Participants were classified as simple snoring and mild, moderate or severe Obstructive sleep apnea syndrome groups depending on the Apnea Hypopnea Index values. Relationship of Apnea hypopnea index was analyzed with age, neck circumference, body mass index and Epworth Sleepiness score. Result Simple snoring was seen in 18(21.17%) patients, 14(16.47%) had mild Obstructive sleep apnea, 13(15.29%) had moderate Obstructive sleep apnea, whereas the severe group consisted of 40(47.05%) patients. The minimum Epworth Sleepiness Score was 10 and the maximum was 25. The Apnea hypopnea index correlated positively with Body mass index (p=.010) and Epworth sleepiness score (p<.001). However, Apnea hypopnea index had no association with age (p=.437) and neck circumference (p=.118). Conclusion Health professionals need to be extremely vigilant while examining patients presenting with Obstructive Sleep Apnea. Polysomnography is the investigation of choice in the early identification of this treatable disease. KEY WORDS Apnea hypopnea index, Obstructive sleep apnea, PolysomnographyPublication Comparison of Two Entry Methods for Laparoscopic Port Entry(Kathmandu University, 2021) Yadav, RP; Paudyal, N; Bhattarai, A; Adhikari, DABSTRACT Background The first step in laparoscopic surgery is to establish the pneumoperitoneum for which many approaches have been introduced to minimize the complications. Although controversies exist regarding the most efficient technique, till now the best entry technique is still unsettled. Objective To compare the safety, operating time and outcome of Direct Trocar Insertion with a well-established and widely practised Open Access Technique. Method This is a prospective study at Nobel Medical College Teaching Hospital from November 2019 to February 2021. Patients were grouped into either of the two groups, Group 1 for Direct Trocar Insertion and Group 2 for Open Access Technique. They were later analysed for major and minor complications of the technique and a comparison of either method was done at the end of the study period. Result A total of 823 patients were enrolled in the study. Among the study population, 411 patients had Direct Trocar Insertion while 412 patients had Open Access Technique. The majority of the operation that was done during the study period was laparoscopic cholecystectomy. Patients in the Open Access Technique group experienced more complications compared to Direct Trocar Insertion group. Conclusion Despite the fear of adopting the Direct Trocar Insertion, this is a safe, better and quick technique for laparoscopic port entry. However, any surgeon practising laparoscopic surgery should be competent to adopt either technique to overcome failure in either process during port entry. KEY WORDS Cholecystectomy, Laparoscopic surgery, PneumoperitoneumPublication Does serum magnesium analysis need to be a part of routine dyselectrolytemia investigation?(Institute of Medicine, 2017) Tuladhar, ET; Pant, V; Aryal, B; Tumbapo, A; Ghimire, S; Sharma, VK; Bhattarai, A; Raut, M; Yadav, BKAbstract Introduction: The fourth most abundant cation in the body and the second most prevalent intracellular cation, magnesium (Mg) is a co-factor for over 300 enzymes. Though magnesium abnormalities frequently accompany other electrolytes abnormalities, during electrolyte investigation, magnesium estimation is often overlooked. This study aims to investigate the occurrence of magnesium abnormalities in serum samples sent, for routine electrolyte measurement like sodium, potassium, calcium and phosphorus, to the biochemistry laboratory of Tribhuvan University teaching hospital. Methods: Serum magnesium measurement was done in 799 serum samples ordered for various electrolyte estimation. Magnesium, Calcium and phosphorus present in sample was analyzed by BT 3500 machine spectrophotometrically. Sodium and potassium ions were analyzed by direct ion selective electrode method. Results: Only 14(1.75%) samples were requested by physician for magnesium estimation out of total 799 samples sent for various electrolyte estimation. When all 799 samples were analyzed for magnesium level, magnesium abnormalities were identified in 76(9.5%), out of which hypermagnesemia was found in 22 (2.75%) and hypomagnesemia in 54 (6.76%) samples. Conclusion: Since, significant numbers of patient's serum sample, sent for estimation of various electrolytes, are found to have magnesium abnormalities, we recommend routine measurement of this analyte along with other electrolytes. Keywords: Magnesium, Sodium, Potassium, Calcium, Phosphorus, DyselectrolytemiaPublication Focal nodular hyperplasia (FNH) of liver in children(Institute of Medicine, 2014) Bhattarai, A; Kansakar, P; Vaidya, PAbstract Introduction: Focal nodular hyperplasia (FNH) is one of the rare benign tumors of liver and second common benign tumour after the haemangioma in adult. It is mostly seen in young middle age women.The actiology of this tumour is unknown; however congenital vascular malformation or vascular injury to the hepatocytes has been suggested as the underlying mechanism for hepatocellular hyperplasia. Its relation with OCP is still controversial2. The tumor is asymptomatic most of the time and detected during routine physical examination or incidentally during radiological investigation. Large lesion presented with abdominal mass and abdominal pain due to pressure effects over surrounding tissue. Only Symptomatic lesion needs treatment. Bleeding and torsion can occur but malignant transformantion never occur in this disease. FNH is very rare in pediatric population Here we report two case of such rare case in pediatric population. Hepatic resection was undertaken in both patients with excellent outcome.Publication Galvanic Skin Response as a Simple Physiology Lab Teaching Tool- An Alternative Indicator of Sympathetic Arousal(Kathmandu University, 2018) Nepal, O; Jha, RK; Bhattarai, A; Khadka, P; Kapoor, BKABSTRACT Background Sympathetic arousal response due to rewarding emotion may not be considered threat to the well-being but such arousal response evoked by fear or punishment can be stressful. When such changes are recorded in lab as biological signals, induced with appropriate stimulus, the observed response may serve as a good indicator of homeostatic alteration. In this study, skin conductance was utilized to record sympathetic response for cognitive load, by application of simple subtraction task. Objective To detect sympathetic arousal by utilization of galvanic skin response during mental arithmetic task. Method Total of eighty two subjects, forty two female and forty male participated in the study. Twenty two subjects were provided mental task to record skin conductance. In sixty subjects, galvanic skin response, pulse rate, respiratory rate and temperature were recorded by appropriate transducers to obtain baseline and task response to detect differential recordings. Subjects performed the mental exercise of arithmetic task (MAT) with transducer placed in upper limbs. Mean of averages for respective variables were statistically calculated from obtained recordings. Result For measured galvanic skin response, 57 subjects showed increased skin conductance (rise in amplitude) whereas, 25 subjects had no rise in amplitude (“A peak”) while performing the mental arithmetic task, when compared to control recording. However, in 20 subjects, pulse rate and respiratory rate showed significant rise though, the change in the skin conductance was not significant. Conclusion Galvanic skin response is useful for demonstration of sympathetic activation induced by simple mental subtraction task, and can be utilized along with vital parameters mentioned in this study to discuss in vivo variation that exist as differential for core and superficial sympathetic outflow among individuals. KEY WORDS Arousal, Conductance, Galvanic, Mental, SympatheticPublication Intestinal obstruction by congenital band(Institute of Medicine, 2018) Bhattarai, A; Bhandari, R; Dahal, GAbstract Congenital bands are rare cause of intestinal obstruction. We report a case of eight year female with features of intestinal obstruction. The patient had no history of abdominal surgery, inflammation and trauma in the past while clinical examination was not diagnostic. Gastrograffin study done revealed no passage of contrast below third part of duodenum. An emergency exploratory laparotomy was subsequently performed which revealed a band compressing the small bowel 10 cm distal to the duodenojejunal flexure which was released. The bowel was examined and found to be healthy. Postoperative course was uneventful. Key words: Congenital bands, Gastrogaffin studyPublication Intraglandular Foreign Body - Unusual Aetiology of Submandibular Gland Sialadenitis(Kathmandu University, 2023) KC, AK; Shrestha, BL; Bhattarai, AABSTRACT Obstructive sialadenitis of submandibular gland is commonly due to sialoliths and strictures in the Wharton’s duct. Other endogenous pathologies include mucous plugs and polyps. Foreign bodies of Wharton’s duct and submandibular gland are rare. Retrograde migration of foreign bodies via ductal orifice, traversing the ductal system to its final intraglandular location is an even rare entity. These often present with painful swelling of the gland and at times with a purulent sialitis. Diagnostic modalities include plain radiography, ultrasonography, sialography, as well as computed tomography and magnetic resonance imaging. Treatment includes antibiotics, incision and drainage of abscess, and removal of foreign body either surgically (intra-oral approach or sialadenectomy) or more recently via sialoendoscopy. This is a case report of 30 years male with accidental cannulation of Wharton’s duct with grass that eventually got lodged in the deep lobe of the gland, and was managed with sialadenectomy. KEY WORDS Foreign body, Submandibular gland, Wharton’s ductPublication Obligate Myiasis: A Case Series From Nepal(Kathmandu University, 2018) Atreya, A; Nepal, S; Bhattarai, A; Kanchan, TABSTRACT Although maggots are unanonymously linked to carcass or dead tissues, there are reports of its infestation into living tissues as well. Myiasis denotes maggot infestation in living tissue. There are two forms of myiasis namely obligate and facultative. Obligate myiasis denotes maggots feeding on living tissue whereas facultative myiasis represents the opportunistic behaviour of the fly taking advantage of wound or necrotic tissue, laying by eggs which hatch into maggots. Decreased physical activity and poor hygiene leads to maggot infestation. Maggot invasion of living tissues is undesirable occurrence which can best be avoided by improving hygiene. People with low living standards in the developing nations are the occasional victims for maggot infestations. We present cases of obligate myiasis for their uniqueness and rarity. KEY WORDS Hygiene, Maggots, MyiasisPublication Right Axillary Mini-thoracotomy approach for surgical correction of Congenital Heart Disease(Institute of Medicine, 2018) Bhattarai, A; Khakural, P; Pradhan, BAbstract Introduction: We describe our initial experience with minimally invasive approach using Peripheral cardiopulmonary bypass (CPBP) and a 4-5 cm long right axillary mini-thoracotomy (RAMT) incision for surgical correction of congenital heart diseases. A right axillary mini-thoracotomy with the aid of peripheral CPBP is a surgical option that has been adopted in our institution in selected patients with congenital heart disease. We present our selection criteria, describe our technique, and analyze our results with this modified technique. Methods: This is retrospective descriptive study conducted at Green city Hospital, Kathmandu and the procedures were followed in accordance with the institutional guidelines for retrospective record review and protection of patient confidentiality. The preoperative variables, intraoperative data and postoperative outcomes of patients undergoing minimally invasive cardiac surgery were collected and analyzed. Results:Total 12 patients were included in the study who underwent a minimally invasive approach with the aid of peripheral CPBP for repairing congenital heart disease (CHD) in our institutions. Main diagnosis leading to surgery included: (1) ostium secundum atrial septal defect in 7 patients, (2) ostium secundum atrial septal defect with moderate tricuspid regurgitation in 3 patients, (3) perimembranous ventricular septal defect with patent ductus arteriosus in 1 patient, (4) ostium secundum atrial septal defect with core triatriatum in 1 patient. There were 6 females and 6 males. Median hospital stay was 4 days. There were no residual intracardiac anomalies at discharge two-dimensional echo, and all patients were satisfied with the surgical approach. Conclusion: The combination of RAMT and peripheral CPBP is safe and effective for treating some congenital heart disease with excellent clinical results. Keywords: congenital heart disease, minimally invasive cardiac surgery, axillary mini thoracotomy.Publication Solid Variant of Alveolar Rhabdomyosarcoma of Nasal Cavity(Kathmandu University, 2020) Bhattarai, A; Shrestha, BL; Dhakal, AABSTRACT Rhabdomyosarcoma comprises about half of the soft tissue tumors. Approximately 40% of the alveolar subtype occur in the head and neck region. Patients present with unilateral nasal mass with/without lymphadenopathy and with/without orbital manifestations. Diagnosis is aided radiologically by CT scan, MRI along with biopsy and is confirmed by immunohistochemistry. Treatment involves surgical resection, chemotherapy, radiotherapy or a combination of these. In spite of treatments, however, the outcome is poor. This is a case report of 14-year-old male who presented with unilateral nasal mass with proptosis of right eye who was eventually diagnosed as a case of alveolar rhabdomyosarcoma of solid variant. KEY WORDS Alveolar rhabdomyosarcoma, Immunohistochemistry, Nasal cavityPublication Thresholds for Spinal Anaesthesia-induced Hypotension During Caesarean Section(Kathmandu University, 2021) Gautam, B; Bhattarai, AABSTRACT Background Spinal anaesthesia is the current standard for caesarean section. Hypotension, a common complication, potentially results in adverse foetal and maternal outcomes. However, hypotension-defining criteria are varied. Objective To identify the blood pressure thresholds for spinal anaesthesia-induced hypotension during caesarean section. Method This is a retrospective cohort study of spinal anaesthesia-induced hypotension that occurred till baby-delivery during caesarean section. Reports on intraoperative hypotension, collected previously from January to December 2019, were reviewed to identify the hypotension-defining thresholds. The thresholds were categorized into systolic blood pressure (SBP) of 80, 90 or 100 mmHg, mean arterial pressure (MAP) of 60, 65 or 70 mmHg, combinations, and others. Parturient and anaesthesia characteristics, and associated hypotensive symptoms were also recorded for descriptive analysis. Result Spinal anaesthesia-induced hypotension was identified in 129 (11.5%) cases among 1116 caesarean sections. Altogether, 12 hypotension-defining thresholds were employed. Thresholds of SBP 90, MAP 60, and SBP 80 mmHg were used in 53 (41%), 28 (21.7%), and 21 (16.2%) cases respectively. Mean maternal age was 28 (±4.22) years and 87 (67.4%) cases underwent emergency surgery. Median sensory blockade level was T4. Nausea-vomiting, bradycardia, and tachycardia were associated during five (3.8%), six (4.6%), and 15 (11.6%) hypotensive incidents respectively. Two cases had unrecordable blood pressure but there was no maternal mortality. Conclusion Systolic blood pressure of 90 mmHg and mean arterial pressure of 60 mmHg included the most common thresholds for spinal anaesthesia-induced hypotension during caesarean section. Identifying the safe and clinically relevant hypotension-defining criteria needs further investigation. KEY WORDS Caesarean section, Criteria, Definition, Hypotension, Spinal anaesthesia, ThresholdPublication Toothbrush, an Unusual Foreign Body(Kathmandu University, 2021) Bhattarai, A; Adhikari, D; Paudyal, N; Giri, P; Khadka, A; Devkota, YABSTRACT Accidental consumption of foreign body is a common presenting complain among patients especially in young age group. Majority of patients can be discharged safely after reassurance while a fraction of patient requires observation and further management. Here we report a case of a 35-year-old gentleman who presented to the out-patient department of our hospital in June 2021 for accidental ingestion of toothbrush. After detailed history and physical examination upper gastrointestinal endoscopy was planned for the patient. Failed endoscopic removal was considered the indication for surgery. A supraumbilical midline incision was used to remove the toothbrush. Following the surgical removal, he was managed conservatively and was discharged without significant complications. We describe this case in detail in addition to reviewing the pertinent literature. KEY WORDS Endoscopy, Foreign body, Surgery